Eating disorders are mental disorders. They develop when a person has an unrealistic attitude toward or abnormal perception of his or her body. This causes behaviors that lead to destructive eating patterns that have negative physical and emotional consequences. Individuals with eating disorders often hide their symptoms and resist seeking treatment. Depression, anxiety disorders, and other mental illnesses often are present in people who have eating disorders, although it is not clear whether these cause the eating disorder or are a result of it

The two best-known eating disorders, anorexia nervosa and bulimia nervosa, have formal diagnostic criteria and are recognized as psychiatric disorders in the Diagnostic and Statistical Manual for Mental Disorders Fourth Edition (DSM-IV-TR) published by the American Psychiatric Association (APA). Other eating disorders have recognized sets of symptoms, but have not been researched thoroughly enough to be considered separate psychiatric disorders as defined by the APA.

Well-known eating disorders

In the North America and Europe, anorexia nervosa is the most publicized of all eating disorders. It gained widespread public attention with the rise of the ultra-thin fashion model. People who have anorexia nervosa are obsessed with body weight. They constantly monitor their food intake and starve themselves to become thin. No matter how much weight they lose, they continue to restrict their calorie intake in an effort to become ever thinner. Some anorectics exercise to extreme or abuse drugs or herbal remedies that they believe will help them burn calories faster. A few purge their body of the few calories they do eat by abusing laxatives, enemas, and diuretics. In time, they reach a point where their health is seriously, and potentially fatally, impaired.

People with anorexia nervosa have an abnormal perception of their body. They genuinely believe that they are fat, even when the clearly are life-threateningly thin. They will deny that they are too thin, or, if they admit they are thin, deny that their behavior will affect their health. People with anorexia will lie to family, friends, and healthcare provides about how much they eat. Many vigorously resist treatment and accuse the people trying to cure them of wanting to make them fat. Anorexia nervosa is the most difficult eating disorder to recover from.

Bulimia nervosa is the only other eating disorder with specific diagnostic criteria defined by the (DSM-IV-TR). People with bulimia often consume unreasonably large amounts of food in a short time. Afterwards, they purge their body of calories. This is done most often by self-induced vomiting, often accompanied by laxative abuse. A subset of people with bulimia does not vomit after eating, but fast and exercise obsessively to burn calories. Both behaviors result in impaired health.

People with bulimia feel out of control when they are binge eating. Unlike people. with anorexia, they

Symptoms of eating disorders

Anorexia nervosa

Bulimia nervosa

Binge-eating disorder

Resistance to maintaining body weight at or above a minimally normal weight for age and height

Recurrent episodes of binge eating, characterized by eating an excerssive amount of food within a discrete period of time and by a sense of lack of control over eating during the episode

Recurrent episodes of binge eating, characterized by eating an excessive amount of food within a discrete period of time and by a sense of lack of control over eating during the episode

Intense fear of gaining weight or becoming fat, even though underweight

Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting or misuse of laxatives, diuretics, enemas, or other medications (purging); fasting; or excessive exercise

The binge-eating episodes are associated with at least 3 of the following: eating much more rapidly than normal; eating until feeling uncomfortably full; eating large amounts of food when not feeling physically hungry; eating alone because of being embarrassed by how much one is eating; feeling disgusted with oneself, depressed, or very guilty after overeating

Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight

The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice week for 3 months

The binge eating occurs, on average, at least 2 days a week for 6 months

Self-evaluation is unduly influenced by body shape and weight

The binge eating is not associated with the regular use of inappropriate compensatory behaviors (e.g., purging, fasting, excessive exercise)

SOURCE: National Institute of Mental Health, National Institutes of Health, U.S. Department of Health and Human Services.

(Illustration by GGS Information Services/Thomson Gale)

recognize that their behavior is abnormal. Often they are ashamed and feel guilty about their behavior and will go to great lengths to hide their binge/purge cycles from their family and friends. People with bulimia are often of normal weight. Although their behavior results in negative health consequences, because they are less likely to be ultra-thin, these consequences are less likely to be life-threatening.

The APA does not formally recognize binge eating as an eating disorder. Binge eating is quite common, but it only rises to the level of a disorder only when bingeing occurs at least twice a week for three months or more. People with binge-eating disorder may eat thousands of calories in an hour or two. While they are eating, they feel out of control and may continue to eat long after they feel full. Binge eaters do not purge or exercise to get rid of the calories they have eaten. As a result, many, but not all, people with binge-eating disorder, are obese, although not all obese people are binge eaters.

Binge eaters are usually ashamed of their behavior and try to hide it by eating in secret and hording food for future binges. After a binge, they usually feel disgusted with themselves and guilty about their eating behavior. They often promise themselves that they will never binge again, but are unable to keep this promise. Binge-eating disorder often takes the form of an endless cycle—rigorous dieting followed by an eating binge followed by guilt and rigorous dieting, followed by another eating binge. The main health consequences of binge eating are the development of obesity-related diseases such as type 2 diabetes, sleep apnea, stroke, and heart attack.

Lesser-known eating disorders

Quite a few eating problems are called disorders even though they do not have formal diagnostic criteria. They fall under the APA definition of eating disorders not otherwise specified. Many have only recently come to the attention of researchers and have been the subject of only a few small studies. Some have been known to the medical community for years but are rare.

Purge disorder is thought by some experts to be a separate disorder from bulimia. It is distinguished from bulimia by the fact that the individual maintains a normal or near normal weight despite purging by vomiting or laxative, enema, or diuretic abuse.

Anorexia athletica is a disorder of compulsive exercising. The individual places exercise above work, school, or relationships and defines his or her self-worth in terms of athletic performance. People with anorexia athletica also tend to be obsessed less with body weight than with maintaining an abnormally low percentage of body fat. This disorder is common among elite athletes.

Muscle dysmorphic disorder is the opposite of anorexia nervosa. Where the anorectic thinks she is always too fat, the person with muscle dysmorphic

KEY TERMS

Fast—a period of at least 24 hours in which a person eats nothing and drinks only water.

Type 2 diabetes—sometime called adult-onset diabetes, this disease prevents the body from properly using glucose (sugar).

disorder believes he is always too small. This believe is maintained even when the person is clearly well muscled. Abnormal eating patterns are less of a problem in people with muscle dysmorphic disorder than damage from compulsive exercising (even when injured) and the abuse of muscle-building drugs such as anabolic steroids.

Orthorexia nervosa is a term coined by Steven Bratman, a Colorado physician, to describe “a pathological fixation on eating ‘proper,’ ‘pure,’ or ‘superior’ foods.” People with orthorexia allow their fixation with eating the correct amount of properly prepared healthy foods at the correct time of day to take over their lives. This obsession interferes with relationships and daily activities. For example, they may be unwilling to eat at restaurants or friends’ homes because the food is impure or improperly prepared. The limitations they put on what they will eat can cause serious vitamin and mineral imbalances. Orthorectics are judgmental about what other people eat to the point where it interferes with personal relationships. They justify their fixation by claiming that their way of eating is healthy. Some experts believe orthorexia may be a variation of obsessive-compulsive disorder.

Rumination syndrome occurs when an individual, either voluntarily or involuntarily, regurgitates food almost immediately after swallowing it, chews it, and then either swallows it or spits it out. Regurgitation syndrome is the human equivalent of a cow chewing its cud. The behavior often lasts up to two hours after eating. It must continue for at least one month to be considered a disorder. Occasionally the behavior simply stops on its own, but it can last for years.

Pica is eating of non-food substances by people developmentally past the stage where this is normal (usually around age 2). Earth and clay are the most common non-foods eaten, although people have been known to eat hair, feces, lead, laundry starch chalk, burnt matches, cigarette butts, light bulbs, and other equally bizarre non-foods. This disorder has been known to the medical community for years, and in some cultures (mainly tribes living in equatorial Africa) is considered normal. Pica is most common among people with mental retardation and developmental delays. It only rises to the level of a disorder when health complications require medical treatment.

Prader-Willi syndrome is a genetic defect that spontaneously arises in chromosome 15. It causes low muscle tone, short stature, incomplete sexual development, mental retardation, and an uncontrollable urge to eat. People with Prader-Willi syndrome never feel full. The only way to stop them from eating themselves to death is to keep them in environments where food is locked up and not available. Prader-Willi syndrome is a rare disease, and although it is caused by a genetic defect, tends not to run in families, but rather is an accident of development. Only 12,000– 15,000 people in the United States have Prader-Willi syndrome.

In general, more women have eating disorders than men. About 90% of people with anorexia and bulimia nervosa are female. Almost as many men as women develop binge-eating disorder. Anorexia ath-letica, muscle dysmorphic disorder, and orthorexia nervosa tend to be more common in men. Rumination, pica, and Prader-Willi syndrome affect men and women equally.

Anorexia nervosa begins primarily between the ages of 14 and 18 and affects mainly white girls. Bulimia usually develops slightly later in the late teens and early twenties. Binge-eating disorder is a problem of middle age and affects blacks and whites equally. Prader-Willi syndrome begins in the toddler years. Not enough is known about the other disorders to determine when they are most likely to develop or which races or ethnic groups are most likely to be at risk.

Depression, low self-worth, and anxiety disorders are all common among people with eating disorders. Some disorders have obsessive-compulsive elements. The association between these psychiatric disorders and eating disorders is strong, but the cause and effect relationship is still unclear.

Personality type can also put people at risk for developing an eating disorder. Low self-worth is common among all people with eating disorders. Binge eaters and people with bulimia tend to have problems with impulse control and anger management. A tendency toward obsessive-compulsive behavior and black-or-white, all-or-nothing thinking also put people at higher risk.

Social and environmental factors also affect the development and maintenance of eating disorders and may trigger relapses during recovery. Relationship conflict, a disordered, unstructured home life, job or school stress, transition events such as moving or starting a new job all seems to act as triggers for some people to begin disordered eating behaviors. Dieting (nutritional and social stress) is the most common trigger of all. The United States in the early twenty-first century is a culture obsessed with thinness. The media constantly send the message through words and images that being not just thin, but ultra-thin, is fashionable and desirable. Magazines aimed mostly at women devote thousands of words every month to diet and exercise advice that creates a sense of dissatisfaction, unrealistic goals, and a distorted body image.

Diagnosis involves four components: a health history, a physical examination, laboratory tests, and a mental status evaluation. Health histories tend to be unreliable, because many people with eating disorders lie about their eating behavior, purging habits, and medication abuse. Based on the health history and physical examination, the physician will order appropriate laboratory tests. Mental status can be evaluated using several different scales. The goal is to get an accurate assessment of the individuals’s physical condition and her thinking in relationship to self-worth, body image, and food.

Treatment depends on the degree to which the individual’s health is impaired. People with anorexia or bulimia may need to be hospitalized or attend structured day programs for an extended period. Some people are helped with antidepressant medication, but the mainstay of treatment is psychotherapy. An appropriate therapy is selected based on the type of eating disorder and the individual’s psychological profile. Some of the common therapies used in treating eating disorders include:

Cognitive behavior therapy (CBT) is designed to confront and then change the individual’s thoughts and feelings about his or her body and behaviors toward food, but it does not address why those thoughts or feelings exist. Strategies to maintain self-control may be explored. This therapy is relatively short-term. CBT is often the therapy of choice for people with eating disorders.

Psychodynamic therapy, also called psychoanalytic therapy, attempts to help the individual gain insight into the cause of the emotions that trigger their dysfunctional behavior. This therapy tends to be more long term than CBT.

Interpersonal therapy is short-term therapy that helps the individual identify specific issues and problems in relationships. The individual may be asked to look back at his or her family history to try to recognize problem areas or stresses and work toward resolving them.

Dialectical behavior therapy consists of structured private and group sessions in which the therapist and patient(s) work at reducing behaviors that interfere with quality of life, finding alternate solutions to current problem situations, and learning to regulate emotions.

Family and couples therapy is helpful in dealing with conflict or disorder that may be a factor in perpetuating the eating disorder. Family therapy is especially useful in helping parents who are anorectics avoid passing on their attitudes and behaviors on to their children.

Eating disorders result in abnormal nutrition that can have life-threatening consequences. A nutritionist or dietitian who can provide nutritional counseling and healthy meal planning is an essential part of the treatment team for any eating disorder. However, nutritional counseling alone will not resolve an eating disorder.

Prevention involves both preventing and relieving stresses and enlisting professional help as soon as abnormal eating patterns develop. Some things that may help prevent an eating disorder from developing are listed below:

Parent should not obsess about their weight, appearance, and diet in front of their children.

Parents should not put their child on a diet unless instructed to by a pediatrician.

Do not tease people about their body shapes or compare them to others.

Make it clear that family members are loved and accepted as they are.

Try to eat meals together as a family whenever possible; avoid eating alone.

Avoid using food for comfort in times of stress.

Monitoring negative self-talk; practice positive self-talk.

Spend time doing something enjoyable every day.

Stay busy, but not overly busy; get enough sleep every night.

Become aware of the situations that are personal triggers for abnormal eating behaviors and look for ways to avoid or defuse them.

Do not go on extreme diets.

Be alert to signs of low self-worth, anxiety, depression, and drug or alcohol abuse and seek help as soon as these signs appear.